Submit a Claim

Submitted By:

*Company Name:

*Street Address:

*City:

*State:

*Zip:

*Contact Name:

*Email Address:

*Phone Number:

Credit or Pay To(if different from above):

Company Name:

Street Address:

City:

State:

Zip:

Contact Name:

Email Address:

Phone Number:

Unit Information:

*Unit Model:

*Unit Serial Number:

*Service Date:

Compressor Model:

Compressor Serial Number:

Facility Name and Number:

Installation Location:

Street Address:

City:

State:

Zip:

Commission Date: (if known)

Service Work Order Number:

Service Invoice Number:

Description of Problem:

Do not submit claim until problem is corrected. Standard warranty coverage is for one year and is for parts only. A copy of the service invoice must accompany submittal form.

Description of service performed and items under warranty:

Requested Amounts:

Labor Cost Requested (in USD):

Material Costs Requested (in USD):

Total of Claim Requested (in USD):

Supporting Documents:

Attach Supporting Document(s):

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